Schult, Lucille iigil
NEW YORK STATE DEPARTMENT OF H h # �� '
Vital Records Section .
i . , Burial -"Transit Permit
Name First Middle Last Sex
Lucille Nina Schult Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 11, 2016 69 War or Dates
IPlace of Death Hospital, Institution or
J!' City, Town or Village Street Address Glens Falls Hospital
W''i Manner of Death LajNatural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
L'ii Stephen Perazzelli, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number i
n0
City, Town or Village 5601 `
0 Burial Date Cemetery or Crematory
April 14, 2016 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z; ri Removal and/or Held
• and/or Address
p Hold
O Date Point of
Transportation Shipment
0) by Common Destination
5 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
Address
cic
lti
a' Permission is hereb granted to dispose of the human r ains de ribed abo e as indicate
Date Issued Registrar of Vital Statistics a �/ , / 1/(-
(signature)
District Number 5601 Place
>
▪ I certify that the remains of the decedent identified above were disposed of in accordance w' h this permit on:
W Date of Disposition 04/14/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2- (address)
W
CO
(section) % _lot numb (grave number)
0 Name of Sexton or Person in Charge f Premises- 4,:irL
(please print)
W Signature a Title nyzinfrpik
(over)
DOH-1555 (02/2004)